College hopes its improvements churn out better prepared grads; some students cry foulBy JESSICA KLIPAjklipa@bradenton.com

With a mounting shortage of critically needed nurses, colleges and universities across the nation are struggling to provide sufficient graduates to staff the health care system.

But with that pressure comes the challenge of educating students who succeed in first getting licensed to practice nursing.

In the past few years, Manatee Community College's nursing program has seen a decline in the passing rates among graduates who take the NCLEX - the National Council Licensure Examination - on their first try, records show.

In 2005, 90 percent of MCC nursing students passed on their first try, compared to 69 percent in 2007. The 2007 passing rate was below both the national and state averages of 85.47 percent and 83.22 percent, respectively.

That decline prompted MCC's administration and faculty to make changes in the program's standards.

"It's not fair to the community. It's not fair to the students when they come through a complete program and they're not successful," said Bonnie Hesselberg, MCC's dean for nursing and health professions.

In response to the dropping NCLEX scores, MCC invited nursing education consultants to evaluate the program, to help improve student success in class and on the NCLEX. In August, the Florida Board of Nursing approved the new measures at MCC, based on recommendations from the consultants.

The most significant changes involved increasing the course passing grade from 75 percent to 80 percent and implementing a comprehensive exam students must pass before graduation.

Effective this fall, students will have two chances to pass a standardized test before they can graduate. Previously, students took the test as only a practice to prepare them for the nursing board exam, she said. A strong "predictor" of how well they will do on the NCLEX, the standardized test helps students know where they need to focus on improving. Learning specialists have even been brought in to help students, Hesselberg said.

The new standards have received resounding applause from local hospitals.

"We support this change very strongly because we think it's going to get the outcome we need," said Jan Mauck, vice president and chief nursing officer for Sarasota Memorial Hospital.

Mauck believes that hospitals and educators have an obligation not only to provide the patient with a well-qualified, knowledgable nurse but also must help students choose a career they will enjoy and can succeed in.

"Every program is interested in making sure they have the highest passing rates possible," she said. "You really have to look at what's the standard."

Student concerned

But students in Manatee Community College's nursing program said changing course requirements in midstream is unfair. This week, about 50 of them crowded into a small meeting room at MCC Bradenton to voice concerns to Hesselberg.

While all recognize the drop in passing rate on the NCLEX calls for a change, students said the new standards are unfair considering that many began the program under a separate set of expectations.

Led by Virginia Rossi, who formed a coalition of MCC nursing students, the group said that their future is at stake. Students unable to obtain an 80 percent to pass exams and the course feared their scholarships could be endangered.

Students said they feel added pressure studying for an exam that was once considered a practice test, but is now part of a final grade.

If the standardized test, which helps predict how students will do on the board exams, is used as a tool to pass or fail students, then it looks like the college is trying to weed students out, Rossi said. She also wants to know why the education received at MCC is not sufficient in preparing students for the board exams.

"Would you have felt the need to implement a grade change if students were passing?" she asked Hesselberg.

Rossi and other students asked that they be grandfathered into the former standards, saying they had come too far into the program for change now.

"We're not asking them to lower the bar and strive for mediocrity, we're asking them to be fair," Rossi said.

Another change with the testing measures came about when the standardized testing company Educational Resources, Inc. was bought out by Assessment Technologies Institute. Familiar with the former testing company and the software and information used to prepare for the exam, students now have little time to become accustomed to the new testing style and prepare for an exam that will be worth 25 percent of their final grade in nursing seminar. Fourth-level students, especially, complained that they had just received their books and study materials and had only until Nov. 4 before they took the test. They also wanted to know how it would be determined whether they passed or failed.

When asked by Hesselberg what could be done to help, their answer was "time."

Hesselberg responded to their pleas saying that the changes were meant to help students achieve their goals. If they applied themselves to their work, they would succeed, she said.

"We certainly have not done this to penalize you," Hesselberg said.

Nurses are required to adapt to different situation each day, she said.

"It's not just textbook (knowledge). Boy, would it be nice it if was," she said. "We hope we're giving you some thinking skills."

It's time to study

Of MCC's more than 300 nursing students, not all students protested the changes.

Michael Zimmermann, a fourth-level student who graduates in December, agreed that time is essential. That's why instead of attending the meeting Monday, he spent his time studying in a group. Zimmermann admits that it has taken more effort to adjust to the changes. When he didn't do well on the first exam, he stepped up his game and improved his grade the next exam. The new challenge is a positive one for the students and the program, he said.

"This is not something that they just made up. This is something they put some thought into," he said. "The only thing that can possibly happen is you'll get better."

Michele Riggs, who also attended the study group, had gone to an open forum at the beginning of the semester to vent. She, too, was not happy initially about the new standards but decided she couldn't do much to change them. A mother of two teenagers and assistant to helping her her husband succeed in his business, she had to buckle down and do what it takes to pass the NCLEX.

"Once we swallowed that, then it was like now it's time to stop whining and study," she said.

Since transition is difficult, measures have been taken to start the incoming students out on the new standards like raising the grade point average requirements and giving an entrance exam, Hesselberg said. MCC has also disbanded the wait list for the program. In fall 2008, there were 343 students on the wait list. MCC invited 125 students into the program; about 70 students accepted. The remaining students who met the new standards were asked to reapply, Hesselberg said.

The new standards, she said, are not out of line with other community colleges. After looking into other programs, she discovered that at least eight of the 28 Florida community colleges have 80 an percent or higher as passing grade per course in nursing program. Fifteen have exit exams.

Instruction in courses, she said, varies depending on the instructor. As long as the concepts are taught, instructors may choose to use round-table discussion and others use straightforward lectures, she said.

Improvement on NCLEX scores has been made in the first quarter of 2008, among those who took the NCLEX for the first time from January until March. MCC's passing rate on the NCLEX was 76 percent, but still below the national and state averages of 87.06 percent and 85.68 percent, respectively.

Preparing for the future

Chief nursing officers in the area meet on a regular basis to discuss preparation of nurses. Hospitals spend time and money on training new nurses to care for the patients on the floor, said Chris Malloy, chief nursing officer at Manatee Memorial Hospital.

"One of the things we have all been grappling with is the preparation of students," she said. "This is a national problem. This is not just an MCC problem."

Malloy, who is pleased with MCC's nursing program, believes that "raising the bar" on the standards will help the community and the graduates in the long run. She looks forward to MCC offering the four-year degree programs, which she believes will be a nice "addition" to the existing two-year program opportunity.

"We believe MCC will certainly rise to the occasion. We're very happy about that," she said.

But a decline in performance on the NCLEX among two-year nursing graduates, begs the question: How will students fare if MCC expands to offer a four-year program?

MCC is not "isolated" in having challenges with its graduates passing the NCLEX, which changes every three years, said MCC president Lars Hafner. A change in the NCLEX back in 2007 caused other institutions, which also dipped below the national average pass rate, to reevaluate their nursing program standards, Hafner said.

New standards were addressed prior to Hafner coming to MCC in July, which enables MCC to "shore up" the nursing process and raise the standards for the future.

"What it does is it sets the foundation to offer a quality four-year program," he said. "You want to confront your problems head on, and that's what MCC has done."

Scrubs belong in the operating room, but what about the subway? (Marko Georgiev for The New York Times)

Should hospital scrubs be worn in public places?

That’s one of the questions asked by my Well column this week, which looks at the role clothing may play in the spread of germs by health workers. The issue of scrubs on the subway and other public places has been raised often by readers of the Well blog.

“I cringe every time I see a medical professional on the subway in their scrubs, which is a regular occurrence,” writes reader A.K.

“What drives me crazy is the sight of someone wearing scrubs while shopping for groceries, going to the post office, picking up their kids from day care, and so on,” writes Jenny, a nurse. “Someone wearing scrubs has been around germs all day. That person is too lazy to keep their patients’ problems away from you, and now they’re handling the apples and cereal boxes that you or someone you love may handle next.”

As my story explains, there’s no evidence that wearing soiled scrubs out of the hospital poses a threat to the public, but part of the problem is that the issue of physician attire and germs hasn’t been well studied. To read more, read the full Well column here, and then post your comments below.

What do you think? Are you bothered when you see someone wearing scrubs in public?

Many hospitals have stepped up efforts to encourage regular hand washing by doctors. But what about their clothes?

Noah Woods

Amid growing concerns about hospital infections and a rise in drug-resistant bacteria, the attire of doctors, nurses and other health care workers — worn both inside and outside the hospital — is getting more attention. While infection control experts have published extensive research on the benefits of hand washing and equipment sterilization in hospitals, little is known about the role that ties, white coats, long sleeves and soiled scrubs play in the spread of bacteria.

The discussion was reignited this year when the British National Health Service imposed a “bare below the elbows” rule barring doctors from wearing ties and long sleeves, both of which are known to accumulate germs as doctors move from patient to patient.

(In the United States, hospitals generally require doctors to wear “professional” dress but have no specific edicts about ties and long sleeves.)

But while some data suggest that doctors’ garments are crawling with germs, there’s no evidence that clothing plays a role in the spread of hospital infections. And some researchers report that patients have less confidence in a doctor whose attire is casual. This month, the medical journal BJU International cited the lack of data in questioning the validity of the new British dress code.

Still, experts say the absence of evidence doesn’t mean there is no risk — it just means there is no good research. A handful of reports do suggest that the clothing of health workers can be a reservoir for risky germs.

In 2004, a study from the New York Hospital Medical Center of Queens compared the ties of 40 doctors and medical students with those of 10 security guards. It found that about half the ties worn by medical personnel were a reservoir for germs, compared with just 1 in 10 of the ties taken from the security guards. The doctors’ ties harbored several pathogens, including those that can lead to staph infections or pneumonia.

Another study at a Connecticut hospital sought to gauge the role that clothing plays in the spread of methicillin-resistant Staphylococcus aureus, or MRSA. The study found that if a worker entered a room where the patient had MRSA, the bacteria would end up on the worker’s clothes about 70 percent of the time, even if the person never actually touched the patient.

“We know it can live for long periods of time on fabrics,” said Marcia Patrick, an infection control expert in Tacoma, Wash., and co-author of the Association of Professionals in Infection Control and Epidemiology guidelines for eliminating MRSA in hospitals.

Hospital rules typically encourage workers to change out of soiled scrubs before leaving, but infection control experts say enforcement can be lax. Doctors and nurses can often be seen wearing scrubs on subways and in grocery stores.

Ms. Patrick, who is director of infection prevention and control for the MultiCareHealth System in Tacoma, says it’s unlikely that brief contact with a scrub-wearing health care worker on the subway would lead to infection. “The likelihood is that the risk is low, but it’s also probably not zero,” she said.

While the role of clothing in the spread of infection hasn’t been well studied, some hospitals in Denmark and Europe have adopted wide-ranging infection-control practices that include provisions for the clothing that health care workers wear both in and out of the hospital. Workers of both sexes must change into hospital-provided scrubs when they arrive at work and even wear sanitized plastic shoes, also provided by the hospital. At the end of the day, they change back into their street clothes to go home.

The focus on hand washing, sterilization, screening and clothing control appears to have worked: in Denmark, fewer than 1 percent of staph infections involve resistant strains of the bacteria, while in the United States, the numbers have surged to 50 percent in some hospitals.

But American hospitals operate on tight budgets and can’t afford to provide clothes and shoes to every worker. In addition, many hospitals don’t have the extra space for laundry facilities.

Ann Marie Pettis, director of infection prevention for the University of Rochester Medical Center, says most hospitals are focusing on hand washing and equipment sterilization, which are proven methods known to reduce the spread of infection. But she adds that her hospital, like many others, has a policy against wearing scrub attire to and from work, even though there is no real evidence that dirty scrubs pose a risk to people in the community.

“Common sense tells us that the things we are wearing as health care providers should be freshly laundered,” Ms. Pettis said. After all, she went on, the wearing of scrubs in public “raises fear” among consumers.

“I don’t think we should feed into that,” she said. “Scrubs shouldn’t be worn out and about.”

The same economics that outsourced call centers and manufacturing jobs overseas may soon hit health care in a big way.

A recent Deloitte study forecasts that the number of people turning to "medical tourism" -- traveling internationally for medical care -- will increase from 750,000 to 6 million by 2010, an eightfold increase.

If the actual increase is even half that, one thing is clear: It will be insurers and employers driving the change, not individual workers.

Blue Cross and Blue Shield of South Carolina has already started down the medical tourism road, and employers in other parts of the country are showing growing curiosity, if not interest.

At the annual Pittsburgh Business Group on Health symposium earlier this month, local benefits managers heard how the Maine-based Hannaford Brothers grocery store chain this year began offering its workers the option to fly to Singapore for their knee replacements, while pocketing an extra $10,000. Because the surgery would be so much cheaper, the company also will pay for a spouse or loved one to accompany them.Medical tourism

Map of popular destinations for medical care, along with the average cost savings and common treatments offered.

The change "was designed to initiate a dialogue about quality and cost," said Chris Washburn, employee benefits supervisor for Hannaford, which is self-insured but uses Aetna as its vendor.

It's certainly started a conversation -- once the Hannaford program was publicized, the company started hearing from hospitals and health systems in the United States that said they could match or beat the Singapore prices. So far, no one from Hannaford has traveled to Singapore for an operation.

All this is not to say the Pittsburgh region is verging on a medical tourism boom.

While Mr. Washburn's presentation last week generated interest among local benefits managers, PBGH Executive Director Christine Whipple said she knew of no local company actively and seriously considering adding medical tourism to employee health benefits plans.

In line with Pittsburgh's historically conservative approach, she said, "They don't want to be leading edge, nor do they want to be far behind."

But as medical tourism becomes a global trend, the world may come to Pittsburgh. If the quality really is comparable, why not fly somewhere that will perform the same surgery for one-tenth the cost?

"The borders of health care have blurred. It is a very different world today than it was five years ago," said Dr. David Jaimovich, chief medical officer of Joint Commission International, which accredits international health systems and hospitals in similar fashion as its sister company, the Joint Commission on Healthcare Organizations, does in the United States.

JCI has given its stamp of approval to more than 250 hospitals in more than 30 countries, he said, and those institutions meet standards that "are very comparable to the U.S. domestic standards. There are many hospitals around the world that would put some of our [U.S.] hospitals to shame."

He expects that number of JCI-accredited hospitals to double by 2012.

At the same time, even accredited hospitals aren't worry free. As the Deloitte report points out, questions remain about follow-up care once a patient returns from overseas, and about who bears responsibility if something goes wrong. In most cases, the regulations and laws of the host country prevail.

"What a lot of folks would say is that the quality of care is highly variable," said Paul Keckley, executive director for Deloitte's Center for Health Solutions, which invested 1,900 hours analyzing the trend.

That does not mean that simple procedures, such as an uncomplicated shoulder surgery, could not be done safely at many centers in many countries, Dr. Keckley said. But he questions the wisdom of traveling overseas for, say, a hip replacement that carries a significant risk of infection or a deep vein thrombosis, when the patient faces a long flight home a few days later.

The Deloitte report estimates that medical tourism by Americans represents a $2.1 billion business. Part of that is a new industry of companies such as BridgeHealth International, which helps insurers, employers and individuals arrange medical travel plans. BridgeHealth advertises that it has "the most extensive provider network in the industry," with 25 hospitals in 10 countries.

The draw is easy to spot: A heart bypass procedure that costs $130,000 in the United States can be done for $18,500 in Singapore or $10,000 in India. A $40,000 knee replacement here is offered at one-fourth that cost in Thailand, all at accredited hospitals.

With health-care costs rising 8 percent to 9 percent domestically, it's the kind of savings that can make medical tourism sound very appealing.

SQUEEZED: One in an occasional series on the pinch of a souring economy and rising pricesMonday, September 22, 2008By Gretchen McKay, Pittsburgh Post-GazetteDarrell Sapp/Post-GazetteJessica and Scott Day sit with their chronically ill son, Scott Jr., at their East Brady, Armstrong County, home.

EAST BRADY, Pa. -- Few things in life are more stressful than a seriously ill child. Just ask Scott and Jessica Day, whose son Scott Jr. was diagnosed in utero with hypoplastic left heart syndrome, a rare congenital defect in which the left side of the heart never fully develops.

Though the condition is often fatal within the first two weeks of life, the Days were optimistic their son would somehow beat the odds, and so far he has, surviving three successive aortic surgeries, infections, seizures, a stroke, fevers, colds and countless one-hour car rides from home to Children's Hospital of Pittsburgh.

"You get to a point where you simply have to lean on your faith," said Mrs. Day.

If caring for a chronically sick child has strained the Armstrong County couple's emotions almost to the breaking point, so has the escalating cost of food and energy. Each 120-mile round trip to the hospital in Oakland, for example, costs them at least $50 out of pocket for gas and parking -- and Scott has been hospitalized more than 100 days since his birth 21/2 years ago. While Mrs. Day is a master of penny-pinching, the $300 she sets aside each month for groceries doesn't buy nearly as much as it used to. A gallon of milk, for instance, recently topped $4.

If she were also working, Mrs. Day noted, they'd probably muddle through these tough times with some creative budgeting. Instead, she had to quit her job as a certified nursing aide to stay home with 5-year-old Maggie and Scott, whose heart rate and blood oxygen levels must be carefully monitored.

Unlike some in their situation, Mr. Day has a good job as a certified nursing aide at Sunnyview Home, a government-run nursing home in Butler County. But the $31,000 he takes home each year barely meets everyday expenses, let alone the ancillary costs of Scott's illness -- especially when factoring in all the unpaid vacation and personal days he's had to take to be at the hospital. The $800 they managed to save before his birth, he notes, was gone in a flash.

"And we're above the level where we're eligible for any assistance," said Mrs. Day, sighing. The only saving grace is that the couple have excellent health insurance through the county, as Scott's medical bills, with the last surgery, have topped $2 million.

Moving from an apartment in Saxonburg to a manufactured home on 13 acres in a rural area a year ago helped cut expenses. But they've still had to skimp in recent months on some very basic needs: both their phone and electric have been disconnected (a loan from Mrs. Day's grandmother got it turned back on) and they've also fallen behind on car payments and insurance. As a result, Mr. Day says, they've had to learn to live off of others' good graces.

Neighbors and friends have been more than generous in passing the hat for incidentals, and many also have given them gas cards and McDonald's Arch cards to defray the cost of their trips to Children's. Their church, Cabot United Methodist Church, helped them catch up on the overdue car payments and regularly fills their refrigerator and pantry; tomorrow, St. Paul's Community Church on state Route 268 in Chicora will sponsor a spaghetti dinner from 4 to 6:30 p.m. to help raise money for a fund set up in Scott's name at a local bank.

"When we hear about a need, we try to help in any way we can," said the Rev. Randall Forester, the church's pastor.

In addition, Mr. Day now sells the eggs a small brood of hens lays each day on their 13-acre property, along with scrap metal he gathers here and there in his beat-up pickup truck.

Yet for every step forward, there's often a step back. Mr. Day had to take even more time off work to battle appendicitis followed by double pneumonia while Mrs. Day underwent gall bladder surgery. Then there are little things like shopping for school clothes and supplies for Maggie, tractor repairs and a recent accident with their dog that cost more than $100 in vet fees.

"It's a never-ending battle," said Mrs. Day. "I'm glad we have a house and a car because our credit is destroyed."

Only time will tell if Scott will suffer developmental problems related to his stroke, but small children typically have a better ability to heal, said his doctor, Dr. Victor Morell. And the early signs are good: Though he tires easily and often gets dehydrated, he laughs and chats and scampers around like any other 2-year-old. If you didn't catch a glimpse of the ragged scar that stretches from just above the belly button to the sternum, you wouldn't even guess he was sick.

"It's pretty good right now," said Mrs. Day.

That said, Scott will need lifelong follow-up care with a cardiologist. The surgical techniques that saved his life have only been in practice for about 20 years, so to date, there are no long-term studies on mortality.

"It's uncertain," said Dr. Morell. "Some kids who go through the surgeries need a transplant at five [years], and then there are kids 10 years out who are doing very well. You just don't know."